Contents

5. Findings

5.1 Overview of Referrals from November 2015 to end of May
2016

The two early adopter sites had received different numbers of
referrals from November 2015 up till May 2016. D&G recorded 299
children and young people who had been seen by the School Nurse
service. P&K recorded 107 for the same period. However, the
team in P&K had had to continue with their immunisation work in
schools in addition to adopting the new role.

Gender

In both areas more girls were referred into the School Nurse
services than boys, although a slightly higher percentage of girls
were seen in D&G than P&K.

Table 3: Numbers and percent of children seen by School
Nurse by gender

Perth and Kinross (n=107)

Dumfries and Galloway (n=299)

Female

53.3%

63.7%

Male

46.7%

36.3%

100%

100%

Age/Year Group

Overall a higher proportion of secondary school children were
referred into the School Nurse service in D&G than in P&K
who had a higher proportion of primary school children referred
in.

Table 4: Percent of children seen by School Nurse by Year
Group

Perth and Kinross (%)

Dumfries and Galloway (%)

Nursery

2

0

P1

14

6

P2

14

4

P3

12

2

P4

7

7

P5

4

2

P6

4

3

P7

4

4

S1

4

9

S2

10

16

S3

8

14

S4

12

18

S5

3

12

S6

1

3

Total

101%

100%

SIMD

P&K appear to have had a lower proportion of children from
SIMD
quintiles 1 and 2 referred into the School Nurse service than
D&G. However it should be noted that there were a high number
of children in D&G where the postcode had not been fully
reported and so it was not possible to ascertain in which quintile
they resided. In addition, both D&G and P&K have a higher
proportion of children living in quintiles 4 and 5 than the
national average so a higher number of referrals from these groups
would be expected for these areas. However, as can be seen from the
table, a higher proportion of the children from the more deprived
SIMD
quintiles were referred to the
SN.

Table 5: Percent of Children referred to School Nurse by
SIMD -
Perth and Kinross

Perth and Kinross

No. children referred to
SN

% of total referrals to
SN

Population of
SIMD
aged 5-19 in P&K

% of
SIMD
population 5-19 referred to
SN

SIMD
1 (most deprived)

11

11%

1355

0.8%

SIMD
2

23

23%

2550

0.9%

SIMD
3

19

19%

5060

0.4%

SIMD
4

35

35%

10357

0.3%

SIMD
5 (least deprived)

13

12%

4833

0.3%

Total

101

100%

24,155

0.4%

No postcode given

6

6%

Note: The populations used to derive the proportions are
weighted according to
ISD
weighting schedule.

Table 6: Percent of Children referred to School Nurse by
SIMD -
Dumfries and Galloway

Dumfries and Galloway

No. children referred to
SN

% of total referrals to
SN

Population of
SIMD
aged 5-19 in D&G

% of
SIMD
population 5-19 referred to
SN

SIMD
1 (most deprived)

56

26%

2243

2.5%

SIMD
2

45

21%

6135

0.7%

SIMD
3

73

34%

8884

0.9%

SIMD
4

34

16%

3919

0.9%

SIMD
5 (least deprived)

6

3%

2076

0.3%

Total

214

100%

23,257

0.9%

No postcode given

84

28%

Note: The populations used to derive the proportions are
weighted according to
ISD
weighting schedule.

Children's Status on and after Referral to School
Nurse

On the whole
HPI status was not
an accurate predictor of the need for referral. Both areas took
referrals from children on Core and Additional
HPIs although
P&K had fewer children referred on additional
HPIs than D&G.
This is despite proportionately more children from primary school
being seen by the P&K nurses.

Table 7: Percent of Children by
HPI status on
referral

Perth and Kinross

Dumfries and Galloway

Additional

21

77

Core

69

16

Pending

4

Unknown

7

7

A certain proportion of children also were referred in because
they were subject to a Child's Plan, they were on the Child
Protection register or they were Looked After (often in kinship
care). However, the figures below also refer to children's status
after intervention by the School Nurse, so they represent children
who had a Child's Plan in place on referral plus those who were
assigned a plan as a result of being referred to the School
Nurse.

Table 8: Percent children referred to School Nurse by
status

Perth and Kinross

Dumfries and Galloway

Child's Plan (after
SN intervention)

24

29

Child Protection

1

6

LAC

3

15

Note: The three columns represent separate groups of children
although any one child could be
LAC, on the Child
Protection Register and have a Child's Plan in place.

5.2 Main themes from the Evaluation

Programme Implementation and the Nine Priority Areas
(Pathways)

It was felt the nine priority areas and pathways provided a
clear framework which ensured only the relevant cases were referred
to the School Nurse. However concern was expressed that there were
some gaps in the priority areas, such as sexual health and physical
health (eg obesity and enuresis) which were not covered.

Some pathways were used far more than others with Mental Health
and Well Being being widely used and pathways such as those for
homelessness and Youth Justice being very little used. This may be
because these early adopter areas experienced lower levels of
child/young person homelessness and involvement in the youth
justice system than is prevalent nationally. However, it was felt
by the
SNs that the Mental Health
and Well Being pathway was sometimes used as a 'catch all' for
occasions when there did not seem to be an appropriate pathway.

Whilst many of the pathways were seen as providing useful
guidance, other pathways, in particular the Mental Health and
Well-being and Substance Abuse were seen as needing further
development.

According to the records, the majority of children were referred
in to the service for mental health and well-being issues. As can
be seen, 68% of those from both P&K and D&G were referred
in to the service because of concerns around a child's mental
health and well-being. There was quite limited representation on
the other pathways, except those children who were Looked After in
D&G. It should be noted, however, that a high proportion of
children in P&K had not been referred into the service on any
particular pathway.

Dumfries and Galloway also reported on the pathways children
were assigned to after meeting with the School Nurse, when School
Nurses might change the pathway following more in-depth assessment.
In this case some 50.5% of children were not given a pathway
presumably because the referral had been declined or the children
had received one episode of care before being discharged.

Table 9: Percent of Children on Pathways at Referral and
after
SN
intervention

Perth and Kinross

Dumfries and Galloway

Before
SN intervention

After
SN intervention

Mental Health and Well-Being

68

68

37

Substance Misuse

0

0.3

Child Protection

0

4

3.3

Domestic Abuse

3

2

2

Looked After Children

0

12

8.4

Homelessness

5

1

0

Youth Justice

3

0

0.3

Young Carers

5

0.3

2.7

Transitions

0

4

2.7

Unknown/Discharged

32

9

50.5

Please note: children could be on more than one pathway, hence
the percentage add up to more than 100%

Referral

Both D&G and P&K developed new referral systems. These
took some time to embed and referrals were slow at the start of the
pilot. In addition
IT issues
affected whether referrals could be made electronically or not.
However, referrals have increased over the period and the demand
for specificity around the needs of the child/young person means
that School Nurses felt that more thought was being given to
referrals. This also helped clarify the role of the School
Nurse.

As can be seen from the table below, school was the main source
of referral, particularly in P&K but Social Work, other health
services and other agencies also referred.

Table 10: Percent of Children referred to School Nurse
Service by referrer

Perth and Kinross

Dumfries and Galloway

Health Services incl
GPs,
HVs and A&E,
CAMHS

7

6

School

92

68

Parent

1

3

Self referral

1

1

Other eg
LAC, Child
Plan Meeting,
SACRO

0

4

Social Work

0

11

Missing

0

8

In terms of referrals that were declined by the School Nurse
team there was some variation between the two areas. School Nurses
in P&K declined nearly 20% of the referrals to them, 65% were
accepted and data is missing on the remaining 16%. In D&G only
5% of referrals were declined. However, there were many cases where
the School Nurse had only seen the child once suggesting that the
School Nurse was in some cases declining the referrals after making
their own assessment.

Table 11: Reasons for Declining Referral
(numbers)

Perth and Kinross (N)

Dumfries and Galloway (N)

Already being seen by another professional
(health or other)

9

2

Parent refused

1

1

Referral did not fit criteria

1

2

School Nurse felt another service was more
appropriate

6

Child did not attend

2

Inadequate Information was given

1

Child did not want support

1

There is confusion as to whether referrals are in fact referrals
or are 'Requests for Assistance' under the 2014 Children's Act.
This needs to be clarified at national level. There is also some
confusion as to the role of the
HPI status of the
child. In one area all children with an Additional
HPI were placed on
the School Nurses' caseload. In another area the School Nurses'
caseload comprised only those children referred in regardless of
HPI status.

Role Clarity and Standardisation

The intention was that several school nurses' duties would be
discontinued to create additional capacity for implementing the
nine priority areas. However, this was not always possible and in
P&K, in particular, School Nurses had to continue to undertake
immunisations. This meant that they could not fully implement the
refocused role. In D&G a team had been created specifically to
undertake immunisations from the
SN budget and this appeared
to work better.

Whilst the refocused role had been designed in some detail and
School Nurses knew what was expected from them there was some lack
of clarity as to the role of members of the wider team.

School Nurses broadly welcomed the more clearly defined role in
terms of validation for their work and clear lines of
responsibility when engaging with other services. However some
nurses felt that the new role was not for them and several staff
resigned, were re-deployed or retired during the course of the
early adoption.

Due to shortage of staff therefore, Band 5 nurses were employed
during the pilot with a view to training them up to undertake the
refocused School Nurse role, but delays in implementing the
training courses and the temporary nature of their contracts meant
that the first round of recruited nurses left for other posts.
Additional Band 5 nurses have since been recruited with a view to
them being trained up as fully qualified School Nurses.

Engagement and Accessibility

It was perceived that the diversity of the priority areas
facilitated engagement with partner agencies in a more positive
way. This has also meant that School Nurses' visibility to other
agencies had improved. Both areas developed Steering Groups which
brought partners together and this was seen as a useful way of
engaging partners. The refocused role has meant that School Nurses
are having more engagement with certain agencies for example, Youth
Justice than previously and this is regarded as a positive
development.

In addition staff at the schools understood the role of the
School Nurse better. However, the refocused role has meant that
School Nurses are less visible to children and young people in the
schools. Increased home visits has meant that some families are
more aware of their role but many children may not meet the School
Nurse unless referred. There was some concern that because School
Nurses were less visible in the schools, children and young people,
especially those who did not wish to go through Pupil Support, were
not able to access the service. D&G have suggested overcoming
this by utilizing a text message service where children can
directly access school nurses, but this may require careful
evaluation.

Training and Support

In P&K only one School Nurse out of 13 held a Specialist
Public Health Qualification (
SPQ) and
in D&G four out of the nine School Nurses held
SPQs and
one member of staff held a Certificate in School Nursing.

It was recognized that adoption of the nine priority areas would
also mean additional training was necessary, over and above that
contained in the
SPQ.
Masters level modules were therefore developed by three Higher
Education Institutes (Robert Gordon University, Queen Margaret
University and University of the West of Scotland) but these had
not come on line during the course of the pilot.

To fill this gap
NES
delivered a 2 day Master Class in the pilot areas and this was
followed by a variety of day courses offered locally covering the
priority areas. The training was widely welcomed. However staff
expressed the view that they needed more in-depth training in the
more commonly used pathways, in particular Mental Health and Well
Being, and regular refresher training in the less well used
pathways, such as Homelessness and Youth Justice where local
conditions could change quite regularly.

The provision of training to staff from local resources proved
very time consuming and stressful for managers but it was
recognized that this was not likely to be a permanent need as staff
undertook more training provided nationally. However the issue of
the provision of
CPD
for qualified nurses in the future may need to be addressed.

Concern was expressed that taking staff away to pursue training
was likely to have a detrimental effect on existing staff capacity
and this would need additional consideration. In addition some
staff need to upgrade their academic skills before undertaking
Masters level modules and this also needs to be factored in to
planning for staff training.

Status of Cases at End of the Early Adoption
period

By the end of May 2016 P&K had closed/discharged 50 (47%) of
its cases and D&G 79 (26%). The difference may have been caused
by D&G Nurses sometimes keeping cases open but on reduced
intervention. Many of the children had been referred on elsewhere,
particularly in the case of P&K. This may indicate a need for
further training in order to build confidence in the skills in the
School Nurse workforce.

Table 12: Percent children with certain Outcomes of
Intervention for Closed Cases

P&K % Outcomes

D&G % Outcomes

Child Development Team

31

Elsewhere in
NHS

2

4

Patient Declined (or
DNAs)

13

1

CAMHS

24

8

GP

7

YPHT

4

Central due to Immunisation

7

Incontinence

2

1

Intervention Completed

11

68

Left school

8

Foster Care

3

Educational Psychology

1

Physiotherapy

1

Social Work

1

Other

3

By the end of the early adoption period around two thirds of
cases were open in D&G and a third in P&K (there was a
relatively high proportion where the outcome was unknown). However
this does not take into account the complexity of cases in the
respective areas, nor whether the term 'open' meant the same in
both areas (in discussion it became apparent that some School Nurse
were keeping cases open so that they could keep a watching brief
over certain children but this did not necessarily entail a high
level of intervention).